Minimally invasive methods of surgical reconstruction of vesicouterine fistulas

Introduction. Vesicouterine fistula (VVF) is a rare disease. In 83-93% of cases it develops due to caesarean section. VVF is characterized by non-physiological communication between the bladder and the uterus. This disorder has a significant social impact, causing incontinence, persistent medical and psychological maladaptation. The gold standard for treating VVF is surgical reconstruction. Early and late results of minimally invasive approaches do not differ from open procedure, but only if the surgical team has sufficient experience.

Aim. To evaluate the efficiency of surgical treatment of VUF using a minimally invasive technique.

Materials and methods: From 2010 to 2021 a total of 15 patients with VVF were treated. The age of the patients varied from 18 to 37 years (mean 26.4 years). The average body mass index was 26.3 kg/m2. The mean maximum fistula diameter was 10.7 mm (from 2 to 25 mm). The predominant cause of VVF was cesarean section (93%; n=14). In one case (7%), radiation-induced VVF was seen. Patients were randomized according to the Jóźwik and Jóźwik classification based on clinical manifestations. A type I of VVF was diagnosed in 4 patients (27%), type II in 9 patients (60%), type III in one woman. Recurrent urinary tract infection was observed in 53% (n=8) of cases. Four women were complaint of chronic pelvic pain syndrome (27%). The pain score on VAS did not exceed 6 points. All patients were undergone to minimally invasive procedures, including robot-assisted approach (n=5; 33%) and laparoscopic access (n=10; 67%).

Results. During the follow-up from 4 weeks to 10 years there was no recurrence of VVF. No indications for hysterectomy were found in any of the cases, however, it was carried out in two women after obtaining the informed consent. The average duration of robot-assisted procedure was 118 min (80–140), compared to 125.5 min (90–160) for laparoscopic access (p>0.05). The average length of stay after robotic procedure was 5.2 days (range 4 to 8 days) and 6.7 days (from 5 to 10 days; p> 0.05), respectively. Intraoperative blood loss did not exceed 130 ml. The mean value for laparoscopy was 97 ml, compared to 82 ml for robot-assisted approach (p>0.05). In both groups, there were no intra- and postoperative complications according to the Clavien-Dindo classification. Thus, there was no significant difference in the results of VVF closure between robot-assisted and laparoscopic approaches.

Conclusion. The results of minimally invasive surgical reconstruction of VVF do not differ from open procedure and depend on timely diagnosis, adherence to strict surgical techniques, and surgical experience, regardless of the approach.